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Pediatric Cardiovascular emergency
The document outlines an approach to pediatric cardiovascular emergencies, emphasizing the complexities of cardiac issues in children, which can be congenital or acquired. It provides detailed management strategies for various conditions such as ductal-dependent lesions, decompensated heart failure, emergency dysrhythmias, and cardiac tamponade. The document highlights the importance of history, physical examination, and initial management without relying solely on echocardiography.
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Pediatric Cardiovascular emergency
- 1. Pediatric Cardiovascular Emergency Approach andinitial management of PCE for pediatrician Dr Hamid Mohammadi Pediatric Cardiologist Shiraz University of Medical sciences – Pediatric Ward Nov 2016 Thanks for Dr Shahraban Abdulla ;Consultant Pediatric Cardiologist; Latifa Hospital, DHA for sharing his presentation in this field
- 2. What we earnwith this presentation Lecture structure Cardiovascular emergency among pediatric emergency department Introduction What we should done Management Guide to correct diagnosis Clue for DDX Sign and Symptom Common Cause What is the presenting scenario Presentation
- 3. Introduction • Cardiac emergenciesare among the most stressful ED presentations. • Cardiac Problem in infancy & childhood are not rare, often are complex. • Cardiac disease in infancy & childhood can be congenital or acquired. • 2nd or 3rd cause of emergency mortality department
- 4. PCE - CommonCauses Ductal Dependent: Pulmonary circulation Dependent Cyanosis Systemic Circulation Dependent Circulatory collapse Decompensated HF Myocardium / Shunt / CHD / Arrhythmia Arrhythmia Sudden event / gradual presentation Tamponed PH crisis
- 5. DUCTAL DEPENDENT CHD withPDA dependency
- 6. Scenario one • A5 days old neonate with cyanosis and irritability since last night – She is product of NVD with no significant prenatal and delivery time history – Now she is tachypnic and has respiratory distress
- 7. Ductal dependent lesion-Causes Systemic Circulation dependent • Presented with Cardiogenic shock and circulatory collapse • The major causes: • Hypoplastic Left Heart Syndrome • Pre-ductal Coarcotation • Interrupted Aortic Arch • Critical Aortic Stenosis Pulmonary circulation dependent • Presented with cyanosis and irritability • The major causes: • Tricuspid Atresia • Pulmonary Atresia • Critical pulmonary stenosis • Ebstein anomaly Functional PA • TGA ?
- 8. Ductal dependent lesion-Presentation Shock (systemic circ.) • Pale an cold • Absent Lower pulse (Femoral pulse detection is critical to Dx) • Wet lung • Hepatomegaly Cyanosis (pulmonic circ.) • Clear lung • No hepatomegaly • Profound cyanosis –Hyperoxia test
- 9. Ductal dependent lesion-Management Critical Neonate PGE1 Cyanotic +++ Collapse +++ O2 therapy Cyanotic ++ Collapse +/- IV fluid Cyanotic Free Hydrate Collapse +/- (Restrict) Inotrope support Cyanotic - Collapse + Anti-PH Rx Cyanotic + Collapse -
- 10. Hyper cyanotic Attack •TOF physiology is the major cause of this attack – May be result of non cardiac source • Presentation: – Period of uncontrollable crying / panic – Rapid and deep breathing (hyperpnoea)- Clear lung – Deepening of cyanosis – ↓heart murmur – Limpness, convulsions – Rarely, death. – Common in Early morning
- 11. Spell Physiology and Tx Painor anxiety Increase catecholamine stat - Decrease SVR - +/- Increase PVR - Tachycardia - Increase shunt Rt Left - Decrease Rt preload Increase cyanosis Treatment strategy: • ↑ SVR • Knee chest position • Phenylephrine • Decrease anxiety: • Hugging Baby • Morphine • O2 therapy • Hydration • Treatment of Acidosis • Inderal (0.01mg/kg Iv slowly) • Sedation and Intubation • Ketamine (↑ SVR)
- 12. DECOMPENSATED HEART The endstage of Cardiac disease
- 13. Scenario Two • A6 month old infant with nausea, vomiting and malaise since 2 weeks ago. Since 2 days ago patient had sporadic cough and also poor feeding – Negative family history of any cardiac disease in childhood – Patient has grunting and R/D – Abdominal exam reveled Hepatomegaly
- 14. Decompensated Heart -Causes • Shunt Pulmonary overflow CHF • Myocarditis • Musculopathy • Metabolic cause • Ischemic cardiomyopathy CHF due to Impaired myocardium • Lt side obstructive (AS- COA …) – usually in early presentation CHF due to obstructive lesion • Any neglected arrhythmia may lead to CHF Tachyarrhythmia induced CHF
- 15. Decompensated Heart –Common Presentation • Different causes lead to similar sign and symptom in the end stage Typical CHF presentation – Diagnostic Clue for HF: • Gallop Rhythm • Hepatomegaly (Rt side failure) • Poor filling pressure (More with Lt side failure) • Cold extremity (More with Lt side failure) • Rales (Lt side Failure)
- 16. Decompensated Heart –Specific Presentation Load P2 • Shunt • Lt side obstructive lesion Different Lower and Upper extremity pulse or HTN • COA PMHx of common cold • Myocarditis Systemic disease (Muscle- Metabolic) • Myopathy • Metabolic Constant rapid pulse or abnormal ECG • Arrhythmia Obstructive Murmur( AS ) • Lt side Obstructive lesion
- 17. Decompensated Heart failure-Management • Usually the most effective Rx +++ • Caution regard obstructive lesion Diuretic Lasix - Spironolactone • Restricted +++ • No Restriction in Obstructive Lesion IV fluid management • Most case recommended ++ • Caution in Obstructive Lesion Inotrope support • Effective ,specially in Lt side failure++ • Contraindicate in Obstructive lesion Captopril • Not essential Rx in Acute Phase • May hold in Arrhythmia • Caution in Myocarditis Digoxin • May be benefit in some case (+/-) • Caution in Shunt and obstructive lesion Anti-PH Rx
- 18. ARRYHTMIA When your artand knowledge are everythings
- 19. Scenario Three A 8years olds girl with palpitation since 2 days ago Patient had Some similar events with spontaneous relief in last year. No relation to exercise A 14 years olds boy with faint during football. Patient is unconscious and no pulse detected
- 20. Emergency Dysrhythmia Causes andPresentation Sudden Death- Tachyarrhythmia • Ventricular origin • VF – VT - Torsade point Gradual course- Tachyarrhythmia •SVT •Slow VT •Atrial Fibrillation /Flutter Brady arrhythmia • Rarely present as sudden event • Fainting and HF is the most common presentation
- 21. Emergency Dysrhythmia -Management Emergency dysrhythmia Pulse present Wide Complex Unstable S. Cardioversion for VT Stable Monomorphic Rhythm (? SVT aberrancy) Adenosine Amiodarone Narrow Complex Unstable S. Cardioversion for SVT Stable Adenosine Amiodarone No Pulse CPR Defibrillation Epinephrine
- 22. TAMPONAD Diagnosis is criticalfor early intervention
- 23. Scenario Four A 4years olds girl with shortness of breath and chest discomfort since 3 days ago He had a history of common cold in two weeks ago that with some OTC drugs improved. The patient is lethargic and heart sound is muffled A 10 years old boy with history of prolonged fever , chest pain and mild tachypnea since one month ago He ecived multiple Antibiotic treatment without significant efficacy Since last night his condition worsen and now he is agitated and can not lying down for examination.
- 24. Tamponade- Causes Viral PericarditisThe most common cause of Pericardial effusion Heart failure Nephrologic cause Renal Failure Nephrotic Syndrome Post cardiac Surgery Tuberculosis Rarely lead to tamponade Malignancy Hypothyroidism Lupus Trauma
- 25. Tamponade - Presentation •Beckes triad is not usual in pediatric and is late finding ( Muffled Heart sound, Engorge Neck vein , Hypotension) • Pulsus paradoxus • Kussmaul's sign • Non specific symptom • Need high index of suspicion to detect • Need Echocardiographic assessment for early intervention
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- 27. Decompensated Heart failure-Management • Indicated in all case of Tamponade or near tamponade Pericadiocentsis or surgical intervention • Contraindicate • Only may be use in HF and Renal failure with caution Diuretic Lasix - Spironolactone • Maintainace or 1.5 time of maintenance • Restriction with repeated evaluation in HF and Renal failure IV fluid management • Not indicated in most case except Heart failureInotrope support • Not indicatedCaptopril - Digoxin • Maintence therapy (after Pericardiocentesis or before it in non symptomatic effusion) Aspirin - NSAID
- 28. Points • History andPhysical exam is the most informative data to select the best management in pediatric Cardiovascular emergency (PCE) • Most of Cardiovascular emergency could be managed without echocardiography in initial visit • Iv fluid handling, Diuretic and inotrope support are the 3 basis of treatment in the PCE
- 29. Research proposal What isthe position of cardiovascula r emergency in our Emergency department visits, morbidity and mortality. What are the most common pitfall & mismanagem ent in approach to PCE in our emergency department Role of Simulation based education in preparing pediatrician for PCE Is it possible to publish a guideline for some common PCE management in our center I’m working on a PCE case book and any cooperation in this field is welcome
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